Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-04150-261 | VA’s Noncompliance with Preaward Review Requirements for Sole-Source Proposals for Healthcare Services | Review | ||
1 The OIG recommends the VHA executive director for procurement ensures contracting officers are requesting preaward reviews for all sole source healthcare resource contracts with an annual value at or above $400,000 in keeping with the May 2018 revisions to VA Directive 1663.
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2 The OIG recommends the VHA executive director for procurement require an OIG preaward review for all interim contracts that exceed the $400,000 annual threshold.
3 The OIG recommends the VHA executive director for procurement mandate an immediate postaward review for any sole source contract awarded on an interim basis as an emergency contract.
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| 19-00226-245 | Lack of Adequate Controls for Choice Payments Processed through the Plexis Claims Manager System | Audit | ||
1 The OIG recommended the VA deputy under secretary for health for the Office of Community Care Define the terms “verifiable usual and customary charges that are billed to payers other than VA” for the PC3/Choice contract claims.
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2 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure future community care programs have applicable definitions and guidance for claims without a Medicare or VA fee schedule rate to avoid reimbursements that pay at “billed charges.”
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3 The OIG recommended the VA deputy under secretary for health for the Office of Community Care create a master usual and customary rate schedule to be used for reimbursement of community care claims without a Medicare or VA fee schedule rate to control program costs.
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4 The OIG recommended the VA deputy under secretary for health for the Office of Community Care provide parties responsible for reimbursing PC3/Choice and future community care program claims with usual and customary rate price schedules and a formal written policy on the proper application of those rates.
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5 The OIG recommended the VA deputy under secretary for health for the Office of Community Care establish controls for verifiable usual and customary rate payment methodology and establish a payment review process to ensure usual and customary rates are properly applied to the PC3/Choice and future community care program payments.
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6 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure payment-rate schedules used by the Plexis Claims Manager and future payment systems to support the PC3/Choice and future community care contracts are current, accurate, and complete to prevent overpayments.
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7 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure that the Office of Community Care determines an appropriate reimbursement process for the identified pass-through errors in this report.
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8 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure the Office of Community Care establishes formal policies and procedures to identify and recover overpayments from PC3/Choice third-party administrators for improperly billed claims.
Closure Date:
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| 19-07062-255 | Greater Consistency Study Participation and Use of Results Could Improve Claims Processing Nationwide | Review | ||
1 The under secretary for benefits directs the Compensation Service to provide the Administration Results Report for each consistency study to the Office of Field Operations and to managers at all regional offices.
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2 The under secretary for benefits ensures the Office of Field Operations develops a process to monitor regional offices to ensure maximum employee participation in consistency studies.
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3 The under secretary for benefits makes certain the Office of Field Operations establishes a requirement for regional office managers to review consistency study results and develop a plan for corrective action based on the performance of their regional office.
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4 The under secretary for benefits requires the Office of Field Operations to develop a follow-up process to confirm all corrective actions identified are completed by regional office managers.
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| 19-07854-272 | Deficiencies in Pharmacy and Nursing Processes at the Southeast Louisiana Veterans Health Care System in New Orleans | Hotline Healthcare Inspection | ||
1 The Southeast Louisiana Veterans Health Care System Director educates pharmacy staff on the Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies related to unaffixed medication labels, and monitors compliance.
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2 The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff comply with the five rights of medication administration prior to administering medications.
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3 The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff administer medications in accordance with physician orders as required by Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies.
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4 The Southeast Louisiana Veterans Health Care System Director confirms that the intensive care unit nursing staff comply with the Southeast Louisiana Veterans Health Care System policy for high-alert and high-risk medications.
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5 The Southeast Louisiana Veterans Health Care System Director validates compliance with obtaining locked boxes to secure controlled substances for intravenous medications administered on the inpatient units.
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6 The Southeast Louisiana Veterans Health Care System Director verifies that facility staff are aware of how to submit Joint Patient Safety Reports that contain complete and accurate information.
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7 The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if peer reviews of relevant clinical staff are warranted.
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8 The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if an institutional disclosure is warranted.
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| 20-00005-271 | Nurse Staffing, Patient Safety, and Environment of Care Concerns at the Community Living Center within the San Francisco VA Health Care System in California | Hotline Healthcare Inspection | ||
1 The San Francisco VA Health Care System Director ensures that the Associate Director for Patient Care Services performs a comprehensive review of Community Living Center nurse staffing methodology, retrains the Nurse Staffing Methodology Coordinator, and develops staffing methodology processes that reflect the needs of the Community Living Center.
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2 The San Francisco VA Health Care System Director continues efforts to recruit and hire for Community Living Center nursing assistants and ensures that alternate staffing strategies are consistently available to meet target nursing hours per patient day until optimal staffing is attained.
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3 The San Francisco VA Health Care System Director confers with facility nursing leadership and the Office of Human Resource Management to identify and mitigate barriers to nursing assistant staff retention and recruitment and takes appropriate action.
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4 The San Francisco VA Health Care System Director consults with VA Sierra Pacific Network and VA Central Office to determine the number and status of approved Community Living Center operating beds and takes action as appropriate.
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5 The San Francisco VA Health Care System Director ensures a review of the episode of care related to Resident B’s elopement to determine if a formal quality management review is needed and takes action accordingly.
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6 The San Francisco VA Health Care System Director evaluates the requirement for Community Living Center registry nursing assistant staff access to the electronic health record system, involving the Office of General Counsel and the Network Contracting Office 21 as appropriate and takes action if needed.
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7 The San Francisco VA Health Care System Director ensures that Environmental Management Services provides Community Living Center staff a clear communication pathway to request assistance for all shifts and confirms its functionality.
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8 The San Francisco VA Health Care System Director establishes comprehensive quality monitoring of the ongoing issue of the presence of flying insects in the Community Living Center, and monitors compliance.
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9 The San Francisco VA Health Care System Director ensures that Community Living Center staff adhere to Veterans Health Administration hand-hygiene policies and ensures that corrective actions are initiated when hand-hygiene performance falls below established thresholds.
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10 The San Francisco VA Health Care System Director ensures a comprehensive review of the registry agency agreement for performance, the provision of nursing assistants as requested, and determines if the agreement meets the needs of the Community Living Center.
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| 19-07828-265 | Deficiencies in Provider Oversight and Privileging Processes at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with the oversight of medical staff, including those with possible physical impairments.
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2 The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with privileging policies.
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3 The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with state licensing board reporting policies.
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4 The Carl Vinson VA Medical Center Director evaluates concerns that the urologist has a possible physical impairment, consults with Human Resources, and takes action, if indicated.
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5 The Carl Vinson VA Medical Center Director reviews current clinical care review processes, identifies areas of noncompliance with facility bylaws, and takes action to ensure compliance.
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6 The Carl Vinson VA Medical Center Director reviews current reduction of privileges processes, identifies areas of noncompliance, and takes action to ensure compliance with Veterans Health Administration policy.
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| 17-00126-267 | Misuse of Funds, Improper Disposal of Equipment, and Destruction of Records | Administrative Investigation | ||
1 The deputy undersecretary for health for the Office of Community Care, with the assistance of the Office of General Counsel as appropriate, ensures that the Office of Community Care’s Equal Employment Opportunity Office and its Revenue Operations group are correctly interpreting and complying with VA Handbook 5975.5 and VA’s Financial Policies and Procedures with regard to the administration of Special Emphasis Programs, including the purchase of food.
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2 The principal executive director and chief acquisition officer of the Office of Acquisition, Logistics and Construction and the deputy undersecretary for health for the Office of Community Care ensure that their staff are appropriately trained on requirements for compliance with VA Directive 6371 governing the destruction of temporary paper records.
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| 19-07103-252 | The Veterans Health Administration’s Governance of Robotic Surgical System Investments Needs Improvement | Audit | ||
1 The OIG recommended the under secretary for health update the high cost, high tech medical equipment application to provide clearer instructions on preparing requests and providing supporting documentation for robotic surgical systems. The application and instructions should be disseminated to medical facilities, Veterans Integrated Service Networks, and responsible central office organizations.
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2 The OIG recommended the under secretary for health establish controls to ensure information in high cost, high tech medical equipment applications is reviewed and validated before recommending final approval to the assistant deputy under secretary for health for administrative operations.
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3 The OIG recommended the under secretary for health evaluate the need and justification of the 10 robotic surgical systems at VA medical facilities that were acquired without approval by the assistant deputy under secretary for health for administrative operations.
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4 The OIG recommended the under secretary for health develop guidance for accurately and consistently coding robotic surgical procedures in the Veterans Health Information Systems and Technology Architecture.
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5 The OIG recommended the under secretary for health evaluate the need for the National Surgery Office to obtain robotic surgical procedure data from the system manufacturer to assess and validate the use of the systems at VA medical facilities.
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| 18-00711-251 | Financial Controls Related to VA-Affiliated Nonprofit Corporations: Idaho Veterans Research and Education Foundation | Audit | ||
1 The Boise VAMC director confers with the Office of General Counsel to determine whether administrative action should be taken against the nonprofit’s current executive director concerning: (a) the processing of salary increases for the former executive director and herself without written authorization and performance evaluations as required by IVREF policies and (b) the failure to report the former executive director’s conduct regarding the salary increase to the board of directors.
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2 The Boise VAMC director makes certain the Idaho Veterans Research and Education Foundation board of directors implements controls requiring two or more responsible officials to provide oversight of all salary and pay rate changes.
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3 The Boise VAMC director ensures the Idaho Veterans Research and Education Foundation board of directors implements controls for the use of credit cards and the receipt, review, and reconciliation of credit card statements.
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4 The Boise VAMC director establishes procedures that require the Research and Development Budget Office staff to review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.
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5 The Boise VAMC director institutes procedures to make certain the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
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| 20-01102-266 | Pharmacy Process Concerns and Improper Staff Communication at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia | Hotline Healthcare Inspection | ||
1 The Hunter Holmes McGuire VA Medical Center Director ensures prescriber education on prior authorization drug request consultation procedures including consult documentation options, urgency level communication, patient notification, and appeals processes.
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2 The Hunter Holmes McGuire VA Medical Center Director promotes mental health prescribers’ utilization of the prior authorization drug request process in consideration of the medication plan most effective for each patient.
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3 The Hunter Holmes McGuire VA Medical Center Director ensures that electronic health records are reviewed for improper entries, and takes action as indicated.
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4 The Hunter Holmes McGuire VA Medical Center Director conducts a review of staff improper electronic health record entries and electronic mail and consults with Office of Human Resources to determine if administrative action is warranted, and takes action as appropriate.
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5 The Hunter Holmes McGuire VA Medical Center Director evaluates ways to improve the workplace relationships between Mental Health and Pharmacy Services staff, including consultation with the Veterans Integrated Services Network or the National Center for Organizational Development, and takes actions as appropriate.
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14957